Dr. Donald Likosky has two main career goals: (1) to understand and identify better the discrete processes of clinical care which produce neurologic injury subsequent to cardiac surgery, and (2) to modify these processes of clinical care during cardiac surgery to reduce a patient's risk of developing a neurologic injury. Great strides have been realized in understanding the mechanisms producing both overt and subtle neurologic injuries. Less work has focused on implementing these findings into daily practice to create lasting improvement. This 5-year project combines the use of outcomes research with continuous quality improvement to redesign processes of cardiac surgery to reduce a patient's risk of developing a neurologic injury. The goal of this research is to identify and redesign modifiable clinical strategies and techniques of surgical and perfusion care associated with the principal causes (thrombotic/lipid emboli, cerebral hypoperfusion &hypotension, and gaseous emboli) of neurologic injury. The current proposal comprises two studies. The first study utilizes intensive neurologic and systemic monitoring at three medical centers in northern New England. In a cohort study design using a focused quality improvement intervention, these medical centers will identify and implement strategies to reduce the principal causes of neurologic injury. Serum will be collected and presence of new neurologic injuries assessed to identify whether these interventions result in less tissue-level and neurologic injury. The second study uses a cohort study design with a focused quality improvement intervention to implement, within the eight medical centers in northern New England conducting cardiac surgery, only those strategies found effective in the first study. Together, these studies are likely to create sustainable reductions in neurologic injury after cardiac surgery by redesigning the processes of care creating them. Cardiac surgery is one of the most common operations performed in the United States, and neurologic injury, broadly speaking, one of the most adverse outcomes from this procedure. The proposed study will likely have a positive impact on public health, through the redesign of cardiac surgery to prevent neurologic injury.